Healthcare providers and insurers are required to execute a business associate agreement (BAA) to safeguard disclosed information and comply with HIPAA when protected health information (PHI) is disclosed to vendors, such as consultants or cloud data storage firms. Although the business associate agreement is a standard procedure, organizations often struggle to manage the risks associated with PHI in these working relationships with vendors.
Due to evolving healthcare technology and modernization across the healthcare system, it is imperative that PHI remains secure. While new, cutting-edge technology allows for advancement and efficiency, it also puts sensitive data at a higher risk for data breaches and ransomware. That said, it’s critical for organizations subject to HIPAA to get ahead of the curve by understanding changes in regulation and evolving cybersecurity concerns.
Learn more about cybersecurity best practices for meeting HIPAA requirements.
HIPAA Violations And The Importance Of Data Security
There are several touchpoints, personnel, and organizations that come in contact with PHI. An impermissible disclosure or use of protected health information is presumed to be a HIPAA breach unless the covered entity illustrates that there is a “low probability” of the PHI being compromised. This is why it’s crucial for organizations to comprehensively assess how they handle PHI, as well as the compliance protocols they have in place to protect patient data.
Smart internet hygiene and robust cybersecurity are critical; without these practices, outside entities may be able to view information that is meant to be kept confidential. As soon as this information has been shared with parties without a patient’s consent, the HIPAA statute has been violated—even if the facility itself never intentionally shared information.
Meeting HIPAA regulations requires a combination of strategic internal processes, specialized technology, and targeted external partnerships.
Primary Practices Central To HIPAA Compliance
There are three primary security components of HIPAA authorization:
The administrative security component regulates information access and security management, security staff, and the evaluation of workforce management, training and security systems. More so, administrative standards work to ensure that all patient information and data are accessible and correct. Here are some other key components of administrative requirements:
- Organizations must create an emergency plan and actively back up patient data
- Employees who are given access to patient data must be identified
- Specific individuals need to be appointed in charge of data security and HIPAA compliance
- Third-party organizations must sign contracts in order to comply with the HIPAA security rule
- Organizations should perform a comprehensive annual data security evaluation
The technical security component encompasses integrity controls, access controls, audit controls, and transmission security to ensure that all technical components are safeguarded against breaches. Here are some other key components of technical requirements:
- After proper identification, respective personnel must be trained on how to avoid social engineering attacks
- Critical files need to be encrypted on cloud-based systems
- Preventive firewalls and systems need to be utilized to protect the healthcare network from cybercriminals
- Passwords must be required to authenticate data transfers to outside parties
- In case of deletion or modifications, data must be consistently backed up
- Employees are required to update their passwords regularly
- Network and technology documentation must be kept up to date
The physical security component limits access to patient data and oversees facility access and control. Physical security, which involves managing physical equipment and their disposal, also involves device and workstation security. Here are some other key components of physical requirements:
- Access to computers must be restricted to keep information safe from the general public
- Organizations must limit access to restricted areas and ensure that visitors are properly signed in
- Staff and contractors must undergo safety training
- Best security practices must be followed upon disposing of software and hardware such as wiping off the hard drive
The HIPAA Security Rule And Electronic PHI
The HIPAA Security Rule is one of the four rules within the HIPAA framework. The framework specifies measures and controls that health providers must practice. Arguably the most complex of all, the Security Rule directly applies to PHI that is electronically transmitted, also known as ePHI.
The Security Rule mandates that organizations must maintain strict security protocols for protecting electronic patient information. Potential threats such as data breaches, theft or information erasure and loss must all be accounted for. Entities bound by the security rule for electronic patient health information must:
- Ensure that the PHI they handle is confidential and correct
- Defend against the misuse or disclosure of this information
- Ensure that employees remain compliant with HIPAA as well
HIPAA Breach Notification Rules And Requirements
HIPAA maintains rules for notifying the public if a breach has occurred. The company must notify individuals that their data may have been compromised, and these requirements expand depending on the number of people involved. If 500 or more individuals’ files are breached, notice must be sent to the media within 60 days.
The Secretary of Health and Human Services must also be notified; in cases of less than 500, this notification may be sent on an annual basis. Otherwise, it must be provided within 60 days of the incident.
Electronic Medical Records In The Healthcare Industry
A significant element of HIPAA compliance is the proper treatment of electronic medical records. These must be transmitted via encryption, and they should be stored securely. However, patients must retain access to their records upon request; thus, cybersecurity and data management measures are critical.
Risk mitigation and data security are the backbones of HIPAA compliance, and failure to adequately implement such strategies could result in significant penalties and consequences.
HIPAA Violations And Penalties In Healthcare
Should your organization be found in violation of HIPAA, whether intentionally or not, the financial penalties may be severe. In cases of willful neglect, fines for a violation can reach up to $1.5 million within a single calendar year. Here is what you can do to bolster your data security to mitigate the risk of a breach—or address a vulnerability that has already occurred.
Mitigate Damage, Restore Operations, And Improve Processes
If patient information has been breached, the first step is to mitigate the damage. Locate the vulnerability and close it as soon as possible—with the help of an expert, if needed. Do not restore operations until the cause of the breach has been addressed.
Mobilize An Incident Response Team And Begin Risk Analysis
One aspect of HIPAA compliance is having an established incident response team. That team should follow the documented and practiced incident response plan.They should also focus on identifying the nature of the breach. Where did the infiltration come from? Could it happen again? Was protected health information actually accessed? Evidence gathered during this stage should be preserved.
Isolate The Affected Systems And Perform Documentation
Once you have gathered information on the nature of the breach, it’s critical to isolate the affected systems so they can be repaired and made secure again and so that attackers can no longer access them. This includes disconnecting the system from the internet and disabling (but not deleting) remote access. This is a good time to change passwords system-wide.
Properly Handle Any Breach Notification Requirements
Depending on the size of your company and the nature of the breach, you may need to inform individuals that their data was compromised. You might also need to contact the media or the Secretary of Health and Human Services, or temporarily host a toll-free number sharing information about the event.
Consider Public Communication And Gather Statements
It is critical for organizations to be honest and transparent about data breach as soon as possible. If appropriate, the incident response team will take steps to engage with the media and gather any statements that could prove useful regarding future risk mitigation efforts.
The Best Risk Mitigation Is Predictive Prevention
It is significantly easier, and less expensive, to prevent and anticipate threats than it is to recover from them—which is why you should establish a comprehensive cybersecurity strategy.
The experts at Hartman Executive Advisors offer an unbiased, third-party view of your organization’s practices to identify vulnerabilities that could cause HIPAA compliance problems in the future.
Whether you are working to improve your systems to prevent data breaches or you have already experienced one and need help, reach out to learn more about Hartman’s risk management consulting services for healthcare organizations.